Request for Medicare Prescription Drug Coverage Determination (coverage criteria)
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Form and instructions for prescribers or authorized representatives to request Medicare prescription drug coverage determinations, including prior authorization, formulary exceptions, tiering exceptions, quantity limits, expedited review, and supporting clinical information. Applies to MVP Health Care enrollees and their prescribers or authorized representatives.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Initial coverage determination criteria
Covered when prescriber provides required supporting information and documentation demonstrating medical necessity or exception criteria are met.
Required for any request
Form contains dedicated sections for DRUG HISTORY and RATIONALE
See RATIONALE FOR REQUEST and Type of Coverage Determination Request sections for required details
Requestor must check expedited review box and sign; prescriber support required for formulary or tiering exceptions
Opioid therapy criteria
Opioid-specific considerations.
Complete the OPIOIDS section on the form
The form does not list any blanket exclusions for coverage determinations; instead coverage is decided based on the documentation submitted. Requests are reviewed when the prescriber provides the required supporting clinical information and completed sections (including diagnosis with ICD-10 codes, medication history, and rationale). For formulary or tiering exception requests, a prescriber statement is required and failure to include it may prevent processing of the request.
An expedited (fast) decision may be requested when waiting the standard timeframe could seriously harm the enrollee’s life, health, or ability to regain maximum function; however, the form explicitly prohibits requesting an expedited coverage determination for the purpose of obtaining reimbursement for a drug that has already been received.
Diagnosis / Codes and Timeframes
| ICD-10 | Diagnoses being treated with the requested drug; form requests corresponding ICD-10 codes |
| CMS-1696 | Authorization of Representation Form |
What the Prescriber or Representative Must Provide
Prior authorization supporting information — highlight required supporting clinical information and use of 'Supporting Information' section on form
Prior authorization and formulary/tiering exception requests require specific supporting clinical information. Use the attached "Supporting Information for an Exception Request or Prior Authorization" form when submitting requests. Formulary and tiering exception requests cannot be processed without a prescriber’s supporting statement. Prior authorization requests may also require supporting information; missing or incomplete supporting clinical documentation may delay processing or result in denial.
Step-therapy exception requirement — prescriber justification and supporting clinical information required for exceptions to step therapy
For step-therapy (fail-first) exception requests, the prescriber must provide a clinical justification explaining why the required prior trial(s) of preferred or step drugs are inappropriate for the enrollee. The prescriber must document the specific drugs tried, dates of trials, outcomes (therapeutic failure or intolerance), maximum doses and duration used, and any adverse reactions or contraindications. If the request is for an expedited review, the prescriber must certify that applying the standard review timeframe may seriously jeopardize the enrollee’s life, health, or ability to regain maximum function.
Required supporting documentation — list of items to attach (enrollee/requestor info, prescriber section, diagnosis with ICD-10, medication history, etc.)
Attach the following supporting documentation with every exception or prior authorization request, as applicable: (1) Enrollee/requestor information (name, member ID, contact information). (2) If requestor is not the enrollee or prescriber: Requestor name, relationship to enrollee, address, phone, and documentation of authority to represent the enrollee (e.g., CMS‑1696 or equivalent). (3) Prescriber section: name, NPI, phone, fax, address, and signed prescriber statement supporting the request. (4) Diagnosis with ICD‑10 code(s) for all conditions being treated. (5) Detailed drug history: current regimen, all drugs tried for the condition, dates of drug trials, results (failure vs intolerance), maximum doses and duration tried, and reason for discontinuation. (6) Medication details for requested drug: name, strength, route, frequency, quantity per 30 days, date started (or NEW START), expected length of therapy, and drug allergies. (7) Rationale for request: clinical rationale showing why alternatives are contraindicated or have failed, clinical risks of medication change if the patient is stable, need for different or higher dosage form, or tiering exception justification. (8) Any relevant clinical records, lab results, or specialist notes that support the request. Failure to include the prescriber’s supporting statement for formulary or tiering exception requests may result in denial.
Missing prescriber statement may cause denial — formulary/tiering exception requests need prescriber's supporting statement
When requesting a formulary or tiering exception, a missing prescriber statement will prevent processing and may lead to denial. Prescribers must complete and sign the supporting information section to attest to clinical necessity, step-therapy exceptions, or tiering exceptions.
| Step therapy details — provide prior trial details and clinical rationale |
|---|
| No results |
Key Definitions and Authorization
Quantity Limit Exceptions
Form Purpose and Scope
This form collects the prescriber’s clinical and medication history needed to evaluate medical necessity and exceptions for prescription drugs. It requests enrollee and requestor identification, a completed prescriber section with diagnosis and corresponding ICD-10 code(s), and detailed drug history (medication names, dates, outcomes, and reasons for discontinuation). The form also includes sections for prior authorization or formulary/tiering/quantity-limit exception rationale, asking for documentation of prior drug trials, contraindications, dosing needs, safety considerations, and any alternate drugs tried or contraindicated so the plan can determine whether coverage criteria are met.
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